Decision Date: 09/12/95 Archive Date:
09/12/95
DOCKET NO. 93-19 755 ) DATE
)
)
On appeal from a decision certified by the
Department of Veterans Affairs Regional Office in St.
Petersburg, Florida
THE ISSUE
Entitlement to an increased disability evaluation for mitral
valve prolapse, currently rated as 30 percent disabling.
REPRESENTATION
Appellant represented by: The American Legion
ATTORNEY FOR THE BOARD
Deborah W. Singleton, Counsel
INTRODUCTION
The veteran served on active duty from June 1954 to November
1957, and from October 1961 to August 1962.
This appeal arises from a rating decision dated in May 1993
by the Department of Veterans Affairs ("VA") Regional Office
("RO") in Montgomery, Alabama, which denied the veteran's
claim seeking entitlement to an increased disability
evaluation for his service-connected mitral valve prolapse.
Service connection for a prolapsed mitral valve was granted
by a Board of Veterans' Appeals ("Board") decision dated in
June 1978. In August 1978, the RO assigned a 30 percent
disability evaluation for mitral valve disease, effective
from November 1976; assigned a temporary total disability
evaluation pursuant to the provisions of 38 C.F.R. § 4.30,
effective from December 1976; and restored the prior 30
percent evaluation, effective from February 1977. The 30
percent evaluation has remained in effect since.
CONTENTIONS OF APPELLANT ON APPEAL
The veteran contends that an increased disability evaluation
is warranted for cardiac problems related to his service-
connected mitral valve prolapse. In support of this
contention, he maintains his heart muscles have deteriorated
and that he currently suffers from heart failure. He claims
these ailments resulted from his surgery for mitral valve
prolapse in 1979. Additionally, he avers that the May 1993
VA compensation examination was inadequate.
DECISION OF THE BOARD
The Board, in accordance with the provisions of 38 U.S.C.A.
§ 7104 (West 1991), has reviewed and considered all of the
evidence and material of record in the veteran's claims
files. Based on its review of the relevant evidence in this
matter, and for the following reasons and bases, it is the
decision of the Board that the evidence warrants the
assignment of a 60 percent evaluation for mitral valve
prolapse.
FINDING OF FACT
The veteran's service connected mitral valve prolapse is
manifested by definite heart enlargement. severe dyspnea on
exertion, and the preclusion of more than light manual
labor.
CONCLUSION OF LAW
The criteria for a 60 percent evaluation for a mitral valve
prolapse have been met. 38 U.S.C.A. § 1155, 5107 (West
1991); 38 C.F.R. § 3.321, 4.7, 4.20, 4.27, 4.104, Diagnostic
Codes 7000, 7016 (1994).
REASONS AND BASES FOR FINDINGS AND CONCLUSION
Factual Background
The veteran has established entitlement to service
connection for mitral valve prolapse, currently evaluated as
30 percent disabling.
A review of the claims file reflects that in April 1962,
when the veteran was examined for separation from active
duty, a Grade I apical systolic murmur was noted. A VA
examination was conducted in July 1963, at which the
diagnoses included a functional murmur of the heart.
Periodically, between August 1976 and October 1977, the
veteran received inpatient and outpatient treatment for
cardiac symptoms which included severe mitral valve
incompetence. During these treatment sessions, various
diagnoses were rendered including severe mitral
regurgitation and mitral valve disease, for which repair of
a prolapsed leaflet of the mitral valve was surgically
performed in December 1976.
Discharge summary records pertaining to inpatient care
provided by the Carraway Methodist Medical Center in
February 1993 reflect that the veteran underwent cardiac
catheterization. A history of a coronary bypass graft with
mitral valvuloplasty in the late 1970's, and a cardiac
catheterization in 1988 was recorded. The veteran was also
reported to have developed progressive dyspnea on exertion
eight to ten months previous to this study, which was
characterized by the appellant's inability to do yard work
or walk up hills without clear-cut angina. Clinical
findings from an October 1992 evaluation by Ronald Stroud,
M.D., were noted and indicated that a graded exercise
tolerance test was negative; that there was a plus or minus
increase in mitral regurgitation; that an afterload
reduction was attempted without much success with Ace
inhibitors in either of the blood pressure symptoms; and
that the veteran's blood pressure was increased. When the
veteran re-presented for follow-up in February 1993, an
echocardiogram revealed severe left ventricular dysfunction,
and akinesis of the apex with mitral regurgitation and
aortic insufficiency. Thereafter hospital admission ensued.
Physical examination on admission, in pertinent part,
disclosed that the veteran's blood pressure was 190/110, and
there was a faint left bruit. The first and second heart
sounds were okay. There was a grade II-III/VI mitral
regurgitation murmur, and a grade I/VI atrial insufficiency
murmur. No third heart sound was noted. The examiner noted
that overall the mitral regurgitation murmur showed an
increase from examination in the 1980's. The lungs were
clear to auscultation and percussion bilaterally. Chest x-
ray revealed no significant interval change, and moderate
enlargement in the left ventricle. Pulmonary vascularity
was normal. An electrocardiogram showed a normal sinus
rhythm with first degree atrioventricular block, a
ventricular rate of 68 beats per minute, and left
ventricular hypertrophy with a principal deflection in an
electrocardiogram ("QRS") finding. The results of the
cardiac catheterization, which were reported by J. G.
Arciniegas, M.D. (the consulting cardiologist) included an
enlarged left ventricle with an ejection fraction of
approximately 35 percent; anterolateral, apical, septal
dyskinesis with mitral regurgitation; a suspected apical
mural thrombus; aortic insufficiency; a left anterior
descending coronary artery at 90 percent at the septal
level; a decreased distal blood flow; and a large, but
normal, right coronary artery. The impression was that
circulation was unchanged from 1986; left ventricular
dysfunction secondary to a left anterior descending coronary
artery with probable chronic irreversible damage; and no
significant mitral regurgitation. Dr. Arciniegas felt that
the veteran's symptoms were probably due to hypertension,
aortic insufficiency and disopyramide; and that the thrombus
appeared chronic. Dr. Arciniegas suggested that the Vasotec
be increased, and that antiarrhythmics be discontinued
unless the arrhythmias were sustained or symptomatic. The
discharge diagnoses were coronary artery disease,
hypertension, and probable apical mural thrombus.
In a February 1993 cardiology consultation report, Dr.
Arciniegas reported that a review of the veteran's heart
revealed that the point of maximal impulse was displaced
downward and to the left. There was a harsh systolic
ejection murmur, II over VI, on the left sternal border,
with a II/VI diastolic blow was detected. A soft mitral
insufficiency murmur was also noted, but no third heart
sound or gallops were heard. Electrocardiogram was
compatible with left ventricular hypertrophy. Chest x-ray
showed cardiomegaly with clear lung fields and no evidence
of pleural effusion. There seemed to be biventricular
enlargement. The assessments were left ventricular
dysfunction, which Dr. Arciniegas felt was the result of
coronary artery disease with ischemic injury to the
territory of the left anterior descending artery; essential
hypertension; a history of hypercholesterolemia; and mild
asymptomatic carotid disease.
Dr. Arciniegas' cardiac catheterization report in February
1993 also included the following conclusions: Coronary
artery disease; a severe segmental wall motion abnormality
to the left ventricle to the territory of the left anterior
descending artery, with an angiographic picture that was
compatible with aneurysmatic formation and apical mural
thrombosis; mild mitral valve prolapse with a puff of mitral
regurgitation; mild sclerosis of the aortic valve leaflet
with mild to moderate aortic insufficiency but no evidence
of aortic stenosis; and reduced filling pressure of the left
ventricle most likely volume depletion, preserved cardiac
index and cardiac output.
Follow-up examination by Dr. Stroud in late February 1993
disclosed mild but increased systolic pressure which ranged
between 160 to 170. Dr. Stroud reported that the veteran's
shortness of breath with exertion had improved but was still
present; that his blood pressure was 150/82; and that his
pulse rate was 86. A review of the cardiovascular system
revealed a Grade I-II/VI mitral regurgitation at Grade I/VI
with aortic insufficiency. The assessments were
arteriosclerotic heart disease, congestive heart failure,
hypertension, and aortic insufficiency with mitral
regurgitation.
VA conducted an examination of the veteran in May 1993. A
past medical history of a mitral valve prolapse repair, and
a one vessel coronary artery bypass was recorded. He
reported that he was seen in February 1993 following
complaints of increased shortness of breath at lower levels
of exertion. He related that he underwent an echocardiogram
and cardiac catheterization during that same time, the
results of which showed an impaired left ventricular
function, mitral regurgitation, and aortic insufficiency.
The veteran denied congestive symptoms at rest, but stated
that he could walk only fifty yards on level ground before
developing shortness of breath. He also complained of
occasional chest pain. A review of the cardiovascular
system revealed that the point of maximal impulse was at the
fifth intercostal space at mid clavicular line "with
murmurs, rubs, or gallops." (Sic) There was no third heart
sound. The veteran's blood pressure was 150/70.
Electrocardiogram showed a normal sinus rhythm, an old
lateral myocardial infarct, and nonspecific ST-T wave
changes. Chest x-ray was interpreted as showing no
infiltrates. The diagnoses were cardiomyopathy by history;
status post mitral valve repair and one vessel coronary
artery bypass graft in 1976; aortic insufficiency and mitral
regurgitation by history; and New York Heart Association
Class III symptoms.
Analysis
The veteran's claim is well-grounded within the meaning of
38 U.S.C.A. § 5107(a). That is, he is found to have
presented a claim which is plausible. The Board is also
satisfied that all relevant facts have been properly
developed. No further assistance to the veteran is required
to comply with the duty to assist as mandated by 38 U.S.C.A.
§ 5107(a).
Disability evaluations are determined by the application of
VA's Schedule for Rating Disabilities which is based on the
average impairment of earning capacity. Separate diagnostic
codes identify the various disabilities. 38 U.S.C.A. §
1155; 38 C.F.R. § 4.1 (1994). Where entitlement to
compensation has already been established and an increase in
the disability rating is at issue, it is the present level
of disability that is of primary concern. Francisco v.
Brown, 7 Vet.App. 55, 58 (1994).
Where there is a question as to which of two evaluations
shall be applied, the higher evaluation will be assigned if
the disability picture more nearly approximates the criteria
required for that rating. Otherwise, the lower rating will
be assigned. 38 C.F.R. § 4.7 (1994).
Where the particular disability for which the veteran is
service-connected is not listed, it may be rated by analogy
to a closely related disease in which not only the functions
affected, but the anatomical location and symptomatology are
closely analogous. 38 C.F.R. §§ 4.20, 4.27 (1994). In this
regard mitral valve prolapse is rated by analogy to
rheumatic heart disease under 38 C.F.R. § 4.104, Diagnostic
Code ("DC") 7000 (1994). See 38 C.F.R. § 4.104, DC 7016
(1994); Lendenmann v. Principi, 3 Vet.App. 345 (1992);
Pernorio v. Derwinski, 2 Vet.App. 625 (1992).
A 30 percent evaluation is warranted inactive rheumatic
heart disease for 3 years from the termination of an
established service episode of rheumatic fever, or its
subsequent recurrence, when there were cardiac
manifestations during the episode or recurrence. A 30
percent evaluation is also in order when there is a
diastolic murmur with characteristic EKG manifestations or a
definite enlarged heart. A 60 percent evaluation requires a
definite enlarged heart; severe dyspnea on exertion,
elevation of systolic blood pressure, or such arrhythmias as
paroxysmal auricular fibrillation or flutter or paroxysmal
tachycardia; and preclusion of more than light manual labor.
38 C.F.R. § 4.104, Diagnostic Code 7000. A 100 percent
evaluation is warranted with definite enlargement of the
heart confirmed by roentgenogram and clinically; dyspnea on
slight exertion; rales, pretibial pitting at end of day or
other definite signs of beginning congestive failure; and by
the preclusion of more than sedentary employment.
Turning to consideration of an increased evaluation for
mitral valve prolapse the Board observes that the clinical
findings contained in private and VA medical reports and
examinations dated between October 1992 and May 1993
collectively show that the veteran was found to have an
enlarged left ventricle, soft mitral and arterial
insufficiency murmurs, a systolic ejection murmur, and chest
x-ray evidence showing cardiomegaly. The May 1993 VA
compensation examination further diagnosed the veteran as
fulfilling the requirements to be a Class III New York Heart
Association patient,1 and the appellant reports progressive
dyspnea on exertion, to include shortness of breath after
walking 50 yards on level ground, as well as an inability to
perform more than light manual labor. In light of the
foregoing, while the Board acknowledges that the veteran's
case is complicated by the veteran's nonservice connected
arteriosclerotic heart disease, after resolving reasonable
doubt in the appellant's favor, the Board concludes that a
60 percent evaluation is warranted. In this respect, the
veteran does show heart enlargement, the inability to walk
more than 50 yards without shortness of breath, and as a
class III New York Heart Association patient, it is at least
as likely as not that more than light manual labor is
precluded. Hence, a 60 percent evaluation for mitral valve
prolapse is warranted.
In awarding a 60 percent evaluation the Board considered
whether a 100 percent evaluation was warranted.
Significantly, however, the veteran's lungs are clear and
without evidence of rales, and there is no evidence of
pretibial pitting, or the preclusion of sedentary
employment. hence, an evaluation in excess of 60 percent is
not warranted.
In reaching this decision the Board considered the
provisions of 38 C.F.R. § 3.321(b), but finds that the
clinical presentation of the veteran's mitral valve prolapse
is neither unusual nor exceptional in nature, and that the
mitral valve prolapse is not shown to have markedly
interfered with employment, or to have required frequent
inpatient care as to render impractical the application of
regular schedular standards. Hence, the assignment of a
total evaluation on an extraschedular basis is not
warranted.
Finally, the Board considered the contention that the
veteran's most recent VA compensation examination was
inadequate, and that it was merely cursory in nature. A
review of his May 1993 VA examination report, however,
reveals no evidence of irregularity, and if he did undergo a
cursory examination, it is difficult to ascertain how the
report came to contain the very specific findings that it
does. The fact that a clinical examination gives rise to
evidence which does not establish entitlement to a total
rating does not render that examination such examination
deficient. Accordingly, the Board concludes that the May
1993 compensation examination report accurately reflects the
findings of that study.
ORDER
Entitlement to a 60 percent evaluation for mitral valve
prolapse is granted, subject to the current laws and
regulations governing the award of monetary benefits.
DEREK R. BROWN
Member, Board of Veterans' Appeals
The Board of Veterans' Appeals Administrative Procedures
Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740,
___ (1994), permits a proceeding instituted before the Board
to be assigned to an individual member of the Board for a
determination. This proceeding has been assigned to an
individual member of the Board.
NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West
1991), a decision of the Board of Veterans' Appeals granting
less than the complete benefit, or benefits, sought on
appeal is appealable to the United States Court of Veterans
Appeals within 120 days from the date of mailing of notice
of the decision, provided that a Notice of Disagreement
concerning an issue which was before the Board was filed
with the agency of original jurisdiction on or after
November 18, 1988. Veterans' Judicial Review Act, Pub. L.
No. 100-687, § 402 (1988). The date which appears on the
face of this decision constitutes the date of mailing and
the copy of this decision which you have received is your
notice of the action taken on your appeal by the Board of
Veterans' Appeals.
1 A functional Class III New York Heart Association patient
has cardiac disease resulting in a marked limitation of
physical activity. The patient is comfortable at rest,
however, ordinary physical activity results in fatigue,
palpitation, dyspnea, or anginal pain. See, Criteria
Committee of the New York Heart Association, DISEASES OF THE
HEART AND BLOOD VESSELS: NOMENCLATURE AND CRITERIA FOR
DIAGNOSIS 112-3 (6th ed. 1964).
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